Covered and non-covered drugs - Aetna

Covered and non-covered

drugs

Drugs not covered -- and their covered alternatives for the Value and Value Plus

pharmacy plans 2019 Formulary Exclusions Drug List

05.03.924.1H (06/19)

July 2019 Formulary Exclusions Drug List

Value and Value Plus pharmacy plans

Category

Not covered

Covered alternatives

Analgesics

Panlor* (acetaminophen/caffeine/dihydrocodeine tab acetaminophen/caffeine/dihydrocodeine cap

325-30-16 mg)

320.5-30-16mg (generic TREZIX)

acetaminophen/caffeine/dihydrocodeine tab

325-30-16 mg

ALLZITAL (butalbital/acetaminophen) bupap butalbital/acetaminophen 50-300mg

butalbital/acetaminophen 50-325mg

CAMBIA (diclofenac)

CONZIP* (tramadol ER capsules)

DEXPAK 6 DAY** (dexamethasone) DEXPAK 10 DAY** (dexamethasone) DEXPAK 13** (dexamethasone) TAPERDEX 6 DAY (dexamethasone)

DUEXIS (ibuprofen/famotidine)

ANAPROX DS** (naproxen) FENORTHO* (fenoprofen calcium) FLECTOR PATCH (diclofenac epolamine) INDOCIN SUPP* (indomethacin) INDOCIN SUSP* (indomethacin) MOBIC** (meloxicam) NAPRELAN* (naproxen sodium) PENNSAID* (diclofenac sodium topical solution) SPRIX (ketorolac trometh nasal spray) TIVORBEX (indomethacin) VIVLODEX (meloxicam) VOLTAREN** (diclofenac) ZIPSOR (diclofenac potassium) ZORVOLEX (diclofenac)

diclofenac potassium (generic CATAFLAM), sumatriptan (generic IMITREX), naratriptan (generic AMERGE), rizatriptan (generic MAXALT) tramadol immediate-release or extendedrelease tablets (generic ULTRAM, ULTRAM ER) dexamethasone tab therapy pack

ibuprofen (generic MOTRIN) plus famotidine (generic PEPCID) Generic oral nonsteroidal antiinflammatory drug

*Generic product is available and is also excluded from coverage. **Generic product is available and is covered as an alternative to the brand-name product

Key UPPERCASE Lowercase italics

Brand-name medicine Generic medicine

Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

Category

Analgesics (continued)

Not covered LAZANDA (fentanyl citrate nasal spray) SUBSYS (fentanyl sublingual spray) LIDODERM** (lidocaine) PRIMLEV (oxycodone/acetaminophen)

RYBIX ODT (tramadol)

VANATOL LQ (acetaminophen/butalbital/ caffeine)

VIMOVO (naproxen/esomeprazole)

Antibiotics

Antidotes Antihyperlipidemic Anti-infectives

ACTICLATE* (doxycycline) ADOXA* (doxycycline) AVIDOXY* (doxycycline) DORYX* (doxycycline) doxycycline hyclate 75 mg, 100 mg delayed-

release tablets doxycycline monohydrate 75 mg capsules MONODOX 75 mg* (doxycycline) MONDOXYNE NL 75 mg capsules ORACEA* (doxycycline) TARGADOX (doxycycline)

COREMINO (minocycline) DYNACIN* tablets (minocycline) MINOLIRA ER (minocycline) SOLODYN (minocycline) XIMINO (minocycline)

FURADANTIN** (nitrofurantoin oral suspension)

ZYVOX** (linezolid)

EVZIO (naloxone HCl injection)

CRESTOR** (rosuvastatin calcium)

FENOGLIDE* (fenofibrate)

LIPITOR** (atorvastatin)

FLOLIPID (simvastatin susp)

ANCOBON** (flucytosine)

NOXAFIL

SOLOSEC (secnidazole)

Covered alternatives fentanyl citrate lozenge (generic ACTIQ)

lidocaine patch 5% oxycodone/acetaminophen (generic PERCOCET, ENDOCET) tramadol immediate-release or extendedrelease tablets (generic ULTRAM, ULTRAM ER) acetaminophen/butalbital/caffeine tablet (generic FIORICET) esomeprazole magnesium (generic NEXIUM) plus naproxen (generic NAPROSYN) doxycycline monohydrate 50 mg, 100 mg capsules (generic MONODOX) doxycycline hyclate 100 mg capsules (generic VIBRAMYCIN) DOXY-D 100 mg capsules MORGIDOX 50 mg, 100 mg capsules

minocycline capsules (generic MINOCIN)

nitrofurantoin linezolid NARCAN nasal spray rosuvastatin Other generic fenofibrates atorvastatin simvastatin (generic ZOCOR) flucytosine itraconazole (generic SPORANOX) metronidazole

*Generic product is available and is also excluded from coverage. **Generic product is available and is covered as an alternative to the brand-name product

Category Antivirals

Cardiovascular

Not covered ZOVIRAX** (acyclovir)

SITAVIG (acyclovir)

TAMIFLU** (oseltamivir) AUVI-Q (epinephrine) CARDIZEM CD** (diltiazem) CADUET* (amlodipine/atorvastatin)

CAROSPIR (spironolactone susp) DIAMOX SEQUEL* (acetazolomide ER) DUTOPROL (metoprolol succinate/

hydrochlorothiazide extended-release tablets)

INDERAL LA** (propranolol ER) metoprolol succinate/hydrochlorothiazide

extended-release tablets RANEXA** (ranolazine er) TEKTURNA** (aliskiren) TEKTURNA HCT** (aliskiren-hctz) VASOTEC** (enalapril maleate) ZYPITAMAG (pitavastatin)

Central nervous system (CNS) -- antidepressants

APLENZIN (bupropion HBr) FORFIVO XL (bupropion HCl extended release) WELLBUTRIN XL** (bupropion extended

release)

LEXAPRO (escitalopram)**

PEXEVA (paroxetine)

CNS -- antiseizure

PRISTIQ** (desvenlafaxine) STAVZOR (valproic acid)

Covered alternatives

acyclovir capsules, tablets, ointment (generic ZOVIRAX) acyclovir capsules, tablets, ointment (generic ZOVIRAX) oseltamivir epinephrine injection, Epi-Pen diltiazem ER

amlodipine (generic NORVASC) plus atorvastatin (generic LIPITOR) spironolactone (generic ALDACTONE) acetazolomide (generic DIAMOX) metoprolol ER (generic TOPROL XL) plus hydrocholorothiazide, metoprolol/ hydrochlorothiazide IR (generic LOPRESS HCR) propranolol ER metoprolol/hydrochlorothiazide tablets (generic LOPRESSOR HCT)

ranolazine er (generic RANEXA) aliskiren (generic TEKTURNA) Aliskiren-hctz (generic TEKTURNA) enalapril maleate rosuvastatin, atorvastatin, simvastatin (generic CRESTOR, LIPITOR, ZOCOR) bupropion immediate or extended release (generic WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL)

escitalopram

paroxetine immediate or extended release (generic PAXIL, PAXIL CR) desvenlafaxine succinate tab er 24 hr valproic acid (generic DEPAKENE)

*Generic product is available and is also excluded from coverage. **Generic product is available and is covered as an alternative to the brand-name product

Category CNS -- sedative/ hypnotics

CNS -- attention deficit hyperactivity disorder (ADHD)

CNS -- other

Dermatological

Not covered ATIVAN** (lorazepam)

Covered alternatives lorazepam

EDLUAR (sublingual zolpidem) INTERMEZZO* (sublingual zolpidem) ZOLPIMIST oral spray (zolpidem)

SILENOR (doxepin)

XANAX** (alprazolam)

XANAX**XR (alprazolam ER)

ADDERALL XR** (amphetamine dextroampetamine)

zolpidem tablets (generic AMBIEN)

doxepin (generic SINEQUAN) alprazolam alprazolam ER amphetamine dextroamphetamine cap er 24 hr

EVEKEO** (amphetamine sulfate)

amphetamine

ZENZEDI 2.5 mg, 7.5 mg, 15 mg, 20 mg, 30 mg (dextroamphetamine sulfate)

dextroamphetamine sulfate (generic DEXEDRINE)

GOCOVRI (amantadine extended release)

amantadine

NAMENDA XR** (memantine

memantine hcl cap er 24 hr

TRANSDERM SCOP** (scopolamine)

scopolamine transdermal patch

ZELAPAR (selegiline)

selegiline (generic ELDERPRYL)

ABSORICA (isotretinoin)

AMNESTEEM, CLARAVIS, MYORISAN

ACANYA gel pump (benzoyl peroxide /clindamycin)

BENZACLIN* (benzoyl peroxide/clindamycin) DUAC* (benzoyl peroxide/clindamycin) NEUAC* (benzoyl peroxide/clindamycin) ONEXTON (benzoyl peroxide/clindamycin)

Topical benzoyl peroxide plus clindamycin

APEXICON E CRE 0.05% (diflorasone diacetate) ATRALIN** (tretinoin) calcipotriene-betamethasone dipropionate oint

CAPEX (fluocinolone) CARAC* (fluorouracil) DENAVIR (penciclovir) ECOZA (econazole)

augmented betamethasone (cream/ointment/lotion/gel)

topical tretinoin (generic RETIN-A, ATRALIN)

calcipotriene CR, oint (generic DOVONEX); betamethasone CR, oint (generic VALISONE, DIPROSONE)

fluocinolone (generic SYNALAR)

topical fluorouracil (generic EFUDEX)

acyclovir capsules, tablets, ointment (generic ZOVIRAX)

econazole cream (generic SPECTAZOLE)

*Generic product is available and is also excluded from coverage. **Generic product is available and is covered as an alternative to the brand-name product

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